Stop Fighting Viruses, Start Treating People

The Obama administration's broad vision of global health.

With the debate over health-care reform in the United States stretching into its second year, Americans are focusing intently on domestic rather than global health issues. But, since taking office, President Barack Obama has introduced a new vision of how to help other countries combat disease and health-care inequality.

On May 5, 2009, Obama unveiled a new global health initiative, dramatically broadening the scope, mission, and size of U.S. health-care initiatives abroad. The president asked Congress to increase global health funding nearly $500 million, to $8.6 billion per year. He also requested a six-year supplemental for the deadliest diseases and special programs, increased funds for U.S. Agency for International Development (USAID) programs, and the expansion of PEPFAR, the President's Emergency Plan for AIDS Relief. In 2009, Washington upped its contributions to multilateral health institutions, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well. And in December, Obama committed to making the largest single contribution for global health ever: $1.05 billion to the Global Fund.

Many in the global health community are concerned that these budgetary requests are still not enough. The Global Fund remains short on cash. And Obama's requests and allotments fall short of the amounts promised in his campaign: $1 billion in annual aid for PEPFAR and $50 billion in total aid by 2013. Still, given the magnitude of the recession and the cost of new health-care spending in the United States, it is an accomplishment.

But what is Obama's new health-care philosophy? And does it really promise to work better?  

Previously, Washington focused its funding on individual diseases, such as AIDS. The Obama administration, in contrast, seeks to tackle broad-category initiatives, most importantly, child and maternal health, family planning, and often-neglected tropical diseases. He also seeks to help other countries strengthen their health-care systems and infrastructure. A May release stated: "We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach to global health."

Obama's top diplomat, Secretary of State Hillary Clinton, demonstrated this new focus -- on populations like women and children, rather than on single viruses -- when speaking on the 15th anniversary of the International Conference on Population and Development. She noted that women are disproportionately affected by HIV and lack access to contraceptives and family planning, and she discussed the high rates of maternal mortality in many countries. She said PEPFAR -- which, when founded in 2003 during former President George W. Bush's administration, focused exclusively on AIDS -- will now tackle related problems. Clinton noted that investing in women and children is among the "smartest" moves government can make -- as investing in women and the young often helps reduce poverty and foster development, in turn improving health outcomes.

When it came to shaping his outlook toward health-care policy in the United States and abroad, Obama cites personal experience as his inspiration. He has cited his mother, Stanley Ann Dunham, as crucial to his understanding of the importance of health. In a speech at the Clinton Global Initiative last September, Obama described her work as an anthropologist in rural Indonesia, providing microcredit to women and villagers via the Ford Foundation and USAID.

But the new approach also reflects the work of researchers and doctors. In 2008, before the announcement of the initiative, doctors Colleen Denny and Ezekiel Emanuel, a White House health-care advisor, wrote an article arguing, "In focusing so heavily on HIV/AIDS treatments, the United States misses huge opportunities. By extending funds to simple but more deadly diseases, such as respiratory and diarrheal illnesses, the U.S. government could save more lives -- especially young lives -- at substantially lower cost." The article advocated a more broad-based approach to reducing mortality in low-income countries.

No less an authority than the World Health Organization concurs. In a 2009 report on women's health, the WHO argues for "Broader strategies, such as poverty reduction, increased access to literacy, training and education, and increased opportunities for women to participate in economic activities, will also contribute to making sustainable progress in women's health. Experience suggests that this requires a gender equal­ity and rights-based approach that harnesses the energy of civil society and recognizes the need for political engagement."

Additionally, the president's initiative reflects the need to help rejuvenate the United States' reputation in and partnerships with other countries. Working closely with other nations to combat disease helps transform other countries' perception of the United States -- integral to what Clinton has called U.S. "smart power."

While Obama certainly faces challenges in implementing his new global health vision, such as the economy and a fragmented bureaucracy, the administration has introduced initiatives that are much needed and long overdue. The next -- and hardest -- step is putting them into action.

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Let Them Leave

Why migration is the best solution for Haiti's recovery.

Long before the calamity in Haiti, many Haitians and their families benefited from working abroad, and many, including me, have suggested allowing more Haitian immigrants into the United States as a way to help the country's economy recover.

It might seem strange that the best solution to Haiti's woes lies outside its borders, but migration and remittances have been responsible for almost all of the poverty reduction that has happened in the island country over the past few decades. They have done enormously more good than any policy intended to reduce poverty inside Haiti during that time. Any poverty-reduction strategy for Haiti going forward that does not include what has been Haitians' most successful poverty-reduction strategy to date is not a serious one.

This idea is a no-brainer if we take a minute to look at the numbers.

First, Haitians have already emigrated in droves. There are around 535,000 Haitian-born U.S. residents at the Census Bureau's last count, out of roughly 1 million in total living abroad.

The vast majority of Haitians who have escaped poverty have done so by leaving the country. Pick any reasonable poverty line for Haiti; the vast majority of Haitians above it no longer live there. In a study I did with Harvard's Lant Pritchett, we chose a bare-bones poverty line of $10 per day (measured as a living standard at U.S. prices). That's total destitution -- just a third of the $30 per day that the United States considers "poverty" for a single adult. Eight out of 10 Haitians above that line currently live in the United States.

Most of this represents the effect of emigration on poverty. Only 1 percent of people in Haiti live on more than $10 per day, and there is no evidence that most Haitian emigrants come from the extreme tip-top of the income distribution, so very few people who emigrated would have an income that high if they had been forced to stay home. A typical low-skill male Haitian in the United States earns at least six times what he could earn in Haiti. And all of this just accounts for Haitians in the United States. Include the roughly 100,000 more who are in Canada and Western Europe, almost all of whom live on over $10 per day, and it's even starker: The vast majority of Haitians who escaped poverty did so by leaving Haiti, not as a result of anything that happened in the country.

What about Haitians who did not emigrate? A limited number of these have emerged from poverty, but many were lifted out of poverty by remittances from abroad. They, too, should be included in any accounting of the effect of migration on poverty. Dilip Ratha, a top expert on remittances, estimates that a full accounting would show that Haitians abroad send home $1.5 billion  to 1.8 billion per year or higher. That is much more than all the foreign aid that Haiti receives. The middle of Ratha's range suggests that remittances account for more than one quarter of Haiti's GDP. This is conservatively low because remittances have a multiplier effect on local GDP.

Living standards in Haiti have not improved in the last 30 years. They've gotten much worse. According to the World Bank, the annual income of the average person in Haiti, measured as a living standard at U.S. prices, steadily declined from $2,400 in 1980 to roughly $1,200 just before the earthquake. It is certainly even lower now.

The poverty inside Haiti would almost certainly be much greater without remittances. Economist Manuel Orozco has shown that remittances to Haiti are primarily spent on the most basic necessities of food, clothing, shelter, and medicine. Because remittances are impossible by definition without emigration, and cover at least a quarter of people's income in Haiti, emigration must have substantially reduced poverty for those back home.

What all of these numbers mean is that the large majority of all poverty reduction that has occurred for Haitians -- whether outside Haiti or inside Haiti -- has been caused by international migration and remittances. Foreign aid has had little or nothing to do with it. The numbers do not allow any other reasonable interpretation.

Why, then, is migration seen as a sideshow as donor countries discuss how best to help Haiti rebuild? Their first step should be to leverage the force that has most helped Haitians in the past. The United States has agreed not to deport any Haitians for a limited period, but it has only been deporting about 1,000 Haitians per year for the past decade. The suspension of deportations will make very little difference in how Haitians are living abroad and sending money home.

The United States has another option for helping Haitians. I propose a new kind of U.S. visa for Haitians and poor people around the world, a Golden Door Visa. This would formally recognize that one of the unwritten goals of immigration policy is global poverty reduction. The Golden Door Visa would not necessarily mean more immigrants. Instead, the United States could reallocate visas within the current levels to include people from the world's poorest countries who are most in need of opportunities. This small adjustment to U.S. immigration policy would have a big impact by improving the lives of poor immigrants and those who remain in their home countries through remittances.

We can do a back-of-the-envelope calculation of what additional migration could do. Suppose the United States lets in 100,000 Haitian immigrants, which is the number that currently arrives over a span of five years. First, this would dramatically raise their incomes and raise essentially all of them out of extreme poverty. Second, this would increase the size of the worldwide Haitian diaspora by 10 percent. If the new migrants remit like earlier migrants did, this would mean roughly $150 million to 180 million every year in additional remittances for Haiti (and because things are so much tougher in Haiti now, we could expect new migrants to remit more than migrants have before). The Guardian reports that as of today the United States has committed a one-time total of $167 million in aid. Remittances recur year after year, and unlike aid, almost the whole amount of remittances goes directly into needy families' pockets.

Of course, migration alone is not "the answer" for all Haitians. Unfortunately, one big answer for all Haitians does not exist. As donors discuss what to do for Haitians going forward, it should be with extreme humility. Billions of dollars of aid have yielded very little poverty reduction there to date. Aid and other measures, such as improved access to U.S. markets,  are worth continuing, of course, but they are unlikely to have dramatically different effects in the near future than they have had for the past two generations.

Migration, on the other hand, has clearly and demonstrably lifted many Haitians out of poverty. It should be an important component of the portfolio of assistance for Haiti. Many people react with fear to statements of this kind, thinking that "more" Haitians is synonymous with "every" Haitian, and that a flood of Haitians would sink the countries they would move to. But the numbers of Haitians moving to the United States has been so small -- just 2 percent of all immigrants to the United States -- that even a substantial increase would hardly constitute a flood.

I discussed these very issues further in a blog post, published the day before Haiti's tragedy, and it is certainly tragic that it took such an event to put the problem on world leaders' agenda.